History: A 27 year old soldier with a reported gunshot wound to the head.

Findings: After immediate resuscitative efforts, an initial chest x-ray was obtained and was negative for signs of trauma or other pathology. Initial head CT showed a keyhole defect high on the parietal bone on the left, impacted bone fragments in the parafalcine region with some pneumocephalus, and a 3 x 3 x 2 cm high parietal subarachnoid hemorrhage and intraparenchymal hemorrhage. No effacement of the basal cisterns, intraventricular bleeding, or midline shift was noted.
Helical CT scan performed the following day after surgical debridement, irrigation, drainage, and closure of the gunshot wound showed that the bilateral high subarachnoid hemorrhage had decreased in size to 3 x 1.5 x 1 cm, intraparenchymal hemorrhage, no midline shift, cisterns present, and bony fragments stable.

Ddx: Keyhole fracture of the skull, grazing missile trauma without penetration of skull, penetrating missile trauma to skull, and blunt trauma to skull.

Dxhow: Diagnosis confirmed by CT

Exam: The patient arrived awake, confused and disoriented, able to open eyes spontaneously, able to obey commands (GCS E4V4M5), with a right hemiparesis. There was a large stellate laceration of the left occiput with extruding brain matter. No other injuries were found.

History: A 27 year old soldier with a reported gunshot wound to the head.

Findings: After immediate resuscitative efforts, an initial chest x-ray was obtained and was negative for signs of trauma or other pathology. Initial head CT showed a keyhole defect high on the parietal bone on the left, impacted bone fragments in the parafalcine region with some pneumocephalus, and a 3 x 3 x 2 cm high parietal subarachnoid hemorrhage and intraparenchymal hemorrhage. No effacement of the basal cisterns, intraventricular bleeding, or midline shift was noted.
Helical CT scan performed the following day after surgical debridement, irrigation, drainage, and closure of the gunshot wound showed that the bilateral high subarachnoid hemorrhage had decreased in size to 3 x 1.5 x 1 cm, intraparenchymal hemorrhage, no midline shift, cisterns present, and bony fragments stable.

Ddx: Keyhole fracture of the skull, grazing missile trauma without penetration of skull, penetrating missile trauma to skull, and blunt trauma to skull.

Dxhow: Diagnosis confirmed by CT

Exam: The patient arrived awake, confused and disoriented, able to open eyes spontaneously, able to obey commands (GCS E4V4M5), with a right hemiparesis. There was a large stellate laceration of the left occiput with extruding brain matter. No other injuries were found.